Protecting EDs & Providers When Patients Leave Against Medical Advice

Recent studies suggest that as many as 2% of discharges from acute care hospitals and EDs in the United States are done against medical advice (AMA). For disadvantaged inner-city facilities, this figure can jump to 6%. “Patients who leave AMA have higher readmission rates,” says Darren P. Mareiniss, MD, JD. “They’re also at greater risk for adverse health effects.” The risk of emergent hospitalization appears highest in the first several days after an AMA discharge. Considering the prevalence and ramifications these discharges can have, Dr. Mareiniss says that “emergency physicians must make every attempt to prevent patients from leaving AMA.” [polldaddy poll=7234675] In the Journal of Emergency Medicine, Dr. Mareiniss and colleagues and the Johns Hopkins Center for Medicine & Law at the Department of Emergency Medicine recently published an article that reviewed legal requirements of the AMA process and examined how properly executed AMA discharges can protect institutions. “In situations when AMA discharge is unavoidable, the key is to optimize legal protection,” Dr. Mareiniss says. Capacity & Disclosing Risks When patients sign out AMA, they must first be deemed as having decision-making capacity. “The assessment of decision-making capacity focuses on a patient’s ability to understand and communicate rational decisions,” explains Dr. Mareiniss. “They need to be able to express their choices and demonstrate an understanding of relevant information. They must also appreciate the significance of this information and its consequences.” Usually, determining capacity is relatively straightforward. However, if capacity is unclear and patients wish to leave AMA, emergency physicians should consult psychiatry whenever feasible. Prolonged observation may be necessary in some situations. In cases of intoxication, mental capacity...